Chronic Medical Conditions

A chronic medical condition is one that has been present for at least six months or longer, such as:

• Asthma
• Cancer
• Cardiovascular disease
• Diabetes
• Musculoskeletal conditions
• Stroke

Chronic Disease Management Plans

A GP Management Plan can help patients with chronic medical conditions by providing an organized approach to care. A GPMP is a plan of action you have agreed with your doctor. This plan:

• identifies your health and care needs;
• sets out the services to be provided by your doctor; and
• lists the actions you can take to help manage your condition

Team Care Arrangements

If you have a chronic medical condition and complex care needs requiring multidisciplinary care, your doctor may also develop Team Care Arrangements (TCAs). These will help coordinate more effectively the care you need from your doctor and other health or care providers.

TCAs require your doctor to collaborate with at least two other health or care providers who will give ongoing treatment or services to you.

Care Plan Reviews

Once a plan is in place, it should be regularly reviewed by your doctor. This is an important part of the planning cycle, where you, your doctor, and our practice nurse check that your goals are being met and agree on any changes that might be needed.

We offer care plans to all eligible patients who suffer from a chronic illness with little or no cost to the patient.

Patients are asked to book an appointment with their doctor to determine if they are eligible. Our practice nurse will provide support and monitoring between visits to your doctor.

If you have any further questions, you can call us at 8390-9500